Introduction

Depression is more than simply feeling unhappy or fed up for a few days.

 Most people go through spells of feeling down, but when you're depressed you feel persistently sad for weeks or months, rather than just a few days.

Some people still think depression is trivial and not a genuine health condition. They're wrong - it is a real illness with real symptoms. Depression isn't a sign of weakness or something you can "snap out of" by "pulling yourself together".

The good news is that with the right treatment and support, most people can make a full recovery.

How to tell if you have depression

Depression affects people in different ways and can cause a wide variety of symptoms.

They range from lasting feelings of sadness and hopelessness, to losing interest in the things you used to enjoy and feeling very tearful. Many people with depression also have symptoms of anxiety.

There can be physical symptoms too, such as feeling constantly tired, sleeping badly, having no appetite or sex drive, and various aches and pains.

The symptoms of depression range from mild to severe. At its mildest, you may simply feel persistently low in spirit, while severe depression can make you feel suicidal, that life is no longer worth living.

Most people experience feelings of stress, unhappiness or anxiety during difficult times. A low mood may improve after a short period of time, rather than being a sign of depression.

When to see a doctor

It's important to seek help from your GP if you think you may be depressed. Many people wait a long time before seeking help for depression, but it's best not to delay. The sooner you see a doctor, the sooner you can be on the way to recovery.

What causes depression?

Sometimes there is a trigger for depression. Life-changing events, such as bereavement, losing your job or even having a baby, can bring it on.

People with a family history of depression are also more likely to experience it themselves. But you can also become depressed for no obvious reason.

Read more about the causes of depression.

Depression is quite common and affects about one in 10 people at some point during their life. It affects men and women, young and old.

Studies have shown that about 4% of children aged five to 16 in the UK are anxious or depressed.

Treating depression

Treatment for depression can involve a combination of lifestyle changes, talking therapies and medication. Your recommended treatment will be based on whether you have mild, moderate or severe depression.

If you have mild depression, your doctor may suggest waiting to see whether it improves on its own, while monitoring your progress. This is known as "watchful waiting". They may also suggest lifestyle measures such as exercise and self-help groups.

Talking therapies, such as cognitive behavioural therapy (CBT), are often used for mild depression that isn't improving or moderate depression. Antidepressants are also sometimes prescribed.

For moderate to severe depression, a combination of talking therapy and antidepressants is often recommended. If you have severe depression, you may be referred to a specialist mental health team for intensive specialist talking treatments and prescribed medication.

Read more about the treatment of depression.

Living with depression

Many people with depression benefit by making lifestyle changes such as getting more exercise, cutting down on alcohol, stopping smoking and eating more healthily.

Reading a self-help book or joining a support group are also worthwhile. They can help you gain a better understanding about what causes you to feel depressed. Sharing your experiences with others in a similar situation can also be very supportive.

Read more about the lifestyle changes you can make to help you beat depression.

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Symptoms

Symptoms of clinical depression 

The symptoms of depression can be complex and vary widely between people. But as a general rule, if you are depressed, you feel sad, hopeless and lose interest in things you used to enjoy.

The symptoms persist for weeks or months and are bad enough to interfere with your work, social life and family life.

There are many other symptoms of depression and you're unlikely to have every one listed below.

Psychological symptoms

Psychological symptoms of depression include:

  • continuous low mood or sadness
  • feeling hopeless and helpless
  • having low self-esteem
  • feeling tearful
  • feeling guilt-ridden
  • feeling irritable and intolerant of others
  • having no motivation or interest in things
  • finding it difficult to make decisions
  • not getting any enjoyment out of life
  • feeling anxious or worried
  • having suicidal thoughts or thoughts of harming yourself

Physical symptoms

Physical symptoms of depression include:

  • moving or speaking more slowly than usual
  • change in appetite or weight (usually decreased, but sometimes increased)
  • constipation
  • unexplained aches and pains
  • lack of energy
  • lack of interest in sex (loss of libido)
  • changes to your menstrual cycle
  • disturbed sleep (for example, finding it difficult to fall asleep at night or waking up very early in the morning)

Social symptoms

Social symptoms of depression include:

  • not doing well at work
  • taking part in fewer social activities and avoiding contact with friends
  • neglecting your hobbies and interests
  • having difficulties in your home and family life

Severities of depression

Depression can often come on gradually, so it can be difficult to notice something is wrong. Many people continue to try to cope with their symptoms without realising they are unwell. It can sometimes take a friend or family member to suggest something is wrong.

Doctors describe depression by how serious it is:

  • mild depression has some impact on your daily life
  • moderate depression has a significant impact on your daily life
  • severe depression makes it almost impossible to get through daily life – a few people with severe depression may have psychotic symptoms

Grief and depression

It can be hard to distinguish between grief and depression. They share many of the same characteristics, but there are important differences between them.

Grief is an entirely natural response to a loss, while depression is an illness.

People who are grieving find their feelings of loss and sadness come and go, but they're still able to enjoy things and look forward to the future.

In contrast, people who are depressed constantly feel sad. They don't enjoy anything and find it hard to be positive about the future.

Read more about coping with grief and bereavement.

Other types of depression

There are different types of depression, and some conditions where depression may be one of the symptoms. These include:

  • Postnatal depression. Some women develop depression after having a baby. This is known as postnatal depression and it is treated in a similar ways to other types of depression, with talking therapies and antidepressant medicines.
  • Bipolar disorder is also known as "manic depression", in bipolar disorder there are spells of depression and excessively high mood (mania). The depression symptoms are similar to clinical depression, but the bouts of mania can include harmful behaviour such as gambling, going on spending sprees and having unsafe sex.
  • Seasonal affective disorder (SAD). Also known as "winter depression", SAD is a type of depression that has a seasonal pattern usually related to winter.
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Causes

There is no single cause of depression. You can develop it for different reasons and it has many different triggers.

For some, an upsetting or stressful life event  such as bereavement, divorce, illness, redundancy and job or money worries  can be the cause.

Different causes can often combine to trigger  depression. For example, you may feel low after being ill and then experience a traumatic event, such as a bereavement, which brings on depression.

People often talk about a "downward spiral" of events that leads to depression. For example, if your relationship with your partner breaks down, you're likely to feel low, so you stop seeing friends and family and you may start drinking more. All of this can make you feel worse and trigger depression.

Some studies have also suggested that you're more likely to get depression as you get older, and that it's more common in people who live in difficult social and economic circumstances.

Some of the potential triggers of depression are discussed below.

Stressful events

Most people take time to come to terms with stressful events, such as bereavement or a relationship breakdown. When these stressful events happen, you have a higher risk of becoming depressed if you stop seeing your friends and family and you try to deal with your problems on your own.

Personality

You may be more vulnerable to depression if you have certain personality traits, such as low self-esteem or being overly self-critical. This may be because of the genes you've inherited from your parents, your early life experiences, or both.

Family history

If someone else in your family has had depression in the past, such as a parent or sister or brother,  it's more likely you will develop it also.

Giving birth

Some women are particularly vulnerable to depression after pregnancy. The hormonal and physical changes, as well as added responsibility of a new life, can lead to postnatal depression.

Loneliness

Becoming cut off from your family and friends can increase your risk of depression.

Alcohol and drugs

Some people try to cope when life is getting them down by drinking too much alcohol or taking drugs. This can result in a spiral of depression.

Cannabis can help you relax, but there is evidence that it can bring on depression, particularly in teenagers.

"Drowning your sorrows" with a drink is also not recommended. Alcohol is categorised as a "strong depressant"  which actually makes depression worse.

Illness

You may have a higher risk of depression if you have a longstanding or life-threatening illness, such as coronary heart disease or cancer.

Head injuries are also an often under-recognised cause of depression. A severe head injury can trigger mood swings and emotional problems.

Some people may have an underactive thyroid (hypothyroidism) due to problems with their immune system. In rarer cases a minor head injury can damage the pituitary gland, a pea-sized gland at the base of your brain that produces thyroid-stimulating hormones.

This can cause a number of symptoms, such as extreme tiredness and a loss of interest in sex (loss of libido), which can in turn lead to depression.

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Diagnosis

If you experience symptoms of depression for most of the day, every day for more than two weeks, you should seek help from your GP.

It is particularly important to speak to your GP if you:

  • have symptoms of depression that are not improving
  • find your mood affects your work, other interests, and relationships with your family and friends
  • have thoughts of suicide or self-harm

Sometimes, when you're depressed it can be difficult to imagine that treatment can actually help. But the sooner you seek treatment, the sooner your depression will improve.

There are no physical tests for depression,  but your GP may examine you and carry out some urine or blood tests to rule out other conditions that have similar symptoms, such as an underactive thyroid.

The main way in which your GP will tell if you have depression is by asking you lots of questions about your general health and how the way you are feeling is affecting you mentally and physically.

Try to be as open and honest as you can be with your answers. Describing your symptoms and how they are affecting you will really help your GP determine whether you have depression and how severe it is.

Any discussion you have with your GP will be confidential. This rule will only ever be broken if there's a significant risk of harm to either yourself or others, and if informing a family member or carer would reduce that risk.

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Treatment

Treating clinical depression 

Treatment for depression usually involves a combination of self-help, talking therapies and medicines.

The treatment that will be recommended will be based on the type of depression you have.

Mild depression

If you have mild depression, the treatments outlined below may be recommended.

  • Wait and see - if you're diagnosed with mild depression, your depression may improve by itself. In this case, you'll simply be seen again by your GP after two weeks to monitor your progress. This is known as watchful waiting.
  • Exercise - there is evidence that exercise may help depression and it is one of the main treatments for mild depression. You may be referred to a qualified fitness trainer for an exercise scheme.
  • Self help groups - Talking through your feelings can be helpful. You could talk to a friend or relative, or you can ask your GP to suggest a local self-help group or search here. Your GP may also recommend self-help books and online cognitive behavioural therapy (CBT).

Mild to moderate depression

If you have mild to moderate depression, the treatments outlined below may be recommended.

  • Talking therapy - If you have mild depression that isn't improving, or you have moderate depression, your GP may recommend a talking treatment (a type of psychotherapy). There are different types of talking therapy for depression including cognitive behavioural therapy (CBT) and counselling. Your GP can refer you for talking treatment or, in some parts of the country, you might be able to refer yourself.

Moderate to severe depression

If you have moderate to severe depression, the treatments outlined below may be recommended.

  • Antidepressants - Antidepressants are tablets that treat the symptoms of depression. There are almost 30 different kinds of antidepressant. They have to be prescribed by a doctor, usually for depression that is moderate or severe.
  • Combination therapy - Your GP may recommend that you take a course of antidepressants plus talking therapy, particularly if your depression is quite severe. A combination of an antidepressant and CBT usually works better than having just one of these treatments.
  • Mental health teams - If you have severe depression, you may be referred to a mental health team made up of psychologists, psychiatrists, specialist nurses and occupational therapists. These teams often provide intensive specialist talking treatments as well as prescribed medication.

Read more detailed information about these and other treatments below.

Talking therapies:

Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT) aims to help you understand your thoughts and behaviour and how they affect you.

CBT recognises that events in your past may have shaped you, but it concentrates mostly on how you can change the way you think, feel and behave in the present.

It teaches you how to overcome negative thoughts, for example being able to challenge hopeless feelings.

CBT is available on the NHS for people with depression or any other mental health problem that it has been shown to help.

You normally have a short course of sessions, usually six to eight sessions, over 10-12 weeks on a one-to-one basis with a counsellor trained in CBT. In some cases, you may be offered group CBT.

Online CBT

Computerised CBT is a form of CBT that's delivered through a computer, rather than face-to-face with a therapist. It is available in some Health Board areas.

You'll have a series of weekly sessions and you should receive support from a healthcare professional. For example, online CBT is usually prescribed by your GP and you may have to use the surgery computer to access the programme.

Ask your GP for more information about the availability of this type of treatment in your area.

Interpersonal therapy (IPT)

Interpersonal therapy (IPT) focuses on your relationships with others and on problems you may be having in your relationships, such as difficulties with communication or coping with bereavement.

There's some evidence that IPT can be as effective as antidepressants or CBT, but more research is needed.

Psychodynamic psychotherapy

In psychodynamic (psychoanalytic) psychotherapy, a psychoanalytic therapist will encourage you to say whatever is going through your mind.

This will help you to become aware of hidden meanings or patterns in what you do or say that may be contributing to your problems. Read more about psychotherapy.

Counselling

Counselling is a form of therapy that helps you think about the problems you are experiencing in your life to find new ways of dealing with them. Counsellors support you in finding solutions to problems, but do not tell you what to do.

Counselling on the NHS usually consists of six to 12 hour-long sessions. You talk in confidence to a counsellor who supports you and offers practical advice.

Counselling is ideal for people who are basically healthy but need help coping with a current crisis, such as anger, relationship issues, bereavement, redundancy, infertility or the onset of a serious illness.

Getting help

See your GP for more information about accessing NHS talking treatments. They can refer you for local talking treatments for depression.

In some parts of the country, you also have the option of self-referral. This means that if you prefer not to talk to your GP you can go directly to a professional therapist.

Antidepressants:

Antidepressants are medicines that treat the symptoms of depression. There are almost 30 different kinds available.

Most people with moderate or severe depression benefit from antidepressants, but not everybody does. You may respond to one antidepressant, but not to another, and you may need to try two or more treatments before you find one that works for you.

The different types of antidepressant work about as well as each other. However, side effects vary between different treatments and people.

When you start taking antidepressants you should see your GP or specialist nurse every week or two for at least four weeks to assess how well they are working. If they are working, you'll need to continue taking them at the same dose for at least four to six months after your symptoms have eased.

If you've had episodes of depression in the past, you may need to continue to take antidepressants for up to five years or longer.

Antidepressants aren't addictive, but be prepared to get some withdrawal symptoms if you stop taking them suddenly or you miss a dose (see below).

Selective serotonin reuptake inhibitors (SSRIs)

If your GP thinks you would benefit from taking an antidepressant, you'll usually be prescribed a modern type called a selective serotonin reuptake inhibitor (SSRI). Examples of commonly used SSRI antidepressants are Seroxat (paroxetine), Prozac (fluoxetine) and Cipramil (citalopram).

They help increase the level of a natural chemical in your brain called serotonin, which is thought to be a ‘good mood’ chemical.

SSRIs work just as well as older antidepressants and have fewer side effects although they can cause nausea, headaches, a dry mouth and problems having sex. However, all these effects usually improve over time.

Some SSRIs aren't suitable for children and young people under the age of 18. Research shows that the risk of self-harm and suicidal behaviour may increase if they're taken by under-18s. Fluoxetine is the only SSRI that can be prescribed for under-18s, and even then only when a specialist has given the go-ahead.

Vortioxetine (Brintellix or Lundbeck) is an SSRI that's recommended by the National Institute for Health and Care Excellence (NICE) for treating severe depression in adults.

Common side effects associated with vortioxetine include abnormal dreams, constipationdiarrhoea, dizziness, itching, nausea and vomiting.

Tricyclic antidepressants (TCAs)

Tricyclic antidepressants (TCAs) are a group of antidepressants that are used to treat moderate to severe depression.

TCAs, including Imipramil (imipramine) and amitriptyline, have been around for longer than SSRIs.

They work by raising the levels of the chemicals serotonin and noradrenaline in your brain. These both help lift your mood.

They're generally quite safe, but it's a bad idea to smoke cannabis if you are taking TCAs because it can cause your heart to beat rapidly.

Side effects of TCAs, which vary from person to person, but may include a dry mouth, blurred vision, constipation, problems passing urine, sweating, light-headedness and excessive drowsiness.

The side effects usually ease after 7 to 10 days, as your body gets used to the medication.

Other antidepressants

New antidepressants, such as Effexor (venlafaxine), Cymbalta or Yentreve (duloxetine) and Zispin Soltab (mirtazapine), work in a slightly different way from SSRIs and TCAs.

Venlafaxine and duloxetine are known as SNRIs (serotonin-norepinephrine reuptake inhibitors). Like TCAs, they change the levels of serotonin and noradrenaline in your brain.

Studies have shown that an SNRI can be more effective than an SSRI,  but they're not routinely prescribed as they can lead to a rise in blood pressure.

Withdrawal symptoms

Antidepressants are not addictive in the same way that illegal drugs and cigarettes are, but when you stop taking them you may have some withdrawal symptoms, including:

  • upset stomach
  • flu-like symptoms
  • anxiety
  • dizziness
  • vivid dreams at night
  • sensations in the body that feel like electric shocks

In most cases, these are quite mild and last no longer than a week or two, but occasionally they can be quite severe. They seem to be most likely to occur with paroxetine (Seroxat) and venlafaxine (Effexor).

Withdrawal symptoms occur very soon after stopping the tablets, so are easy to distinguish from symptoms of depression relapse, which tend to occur after a few weeks.

Common questions about antidepressants answered:

How long does it take for antidepressants to work?

It usually takes around seven days before you begin to notice the effects of antidepressants. Contact your doctor if you haven't noticed any improvement after four weeks, as they may recommend increasing your dose or trying an alternative antidepressant.

During this time, you may experience side effects such as:

  • anxiety and agitation
  • drowsiness
  • blurred vision
  • nausea (feeling sick)

These side effects can be unpleasant at first, but it's important to persist with treatment as your body will usually get used to the medication over time.

How antidepressants work

Antidepressants work by increasing the levels of chemicals in your brain called neurotransmitters. The levels of neurotransmitters will rise gradually. This is why most people will need to take antidepressants for a few weeks before they start to work.

It's important that you continue to take your medicine at the prescribed dose to give it time to work properly. You should take your antidepressants for at least four to six weeks to see if they're effective. If they still aren't working after this time, your GP may consider changing to a different type or increasing the dose.

Stopping antidepressants

You shouldn't stop taking antidepressants suddenly, as this can cause withdrawal symptoms such as:

  • flu-like symptoms
  • dizziness
  • vivid dreams
  • sensations in your body that feel like electric shocks

If you have been taking antidepressants for at least four weeks and you have felt little or no benefit, speak to your doctor. They may recommend increasing your dose or changing to a different antidepressant.

If you want to stop taking antidepressants, your doctor will normally reduce your dose gradually over a four-week period to reduce withdrawal symptoms.

Can I drink alcohol if I'm taking antidepressants?

Drinking alcohol while taking antidepressants is generally not advised because alcohol can make depression worse and it can increase the side effects of some antidepressants, such as drowsiness, dizziness and co-ordination problems.

Therefore, it’s best to avoid drinking alcohol if you are taking antidepressants, particularly if you are going to drive or operate machinery.

Advice for different types of antidepressants

The information and advice below is specific to the different types of antidepressants that are available:

  • Selective serotonin re-uptake inhibitors (SSRIs) –  generally do not cause problems when taken with alcohol and it may be safe to drink alcohol while taking them, however, the  manufacturers advise avoiding alcohol during treatment because it might make you feel drowsy
  • Tricyclic antidepressants (TCAs) – TCAs can make you feel drowsy and affect your co-ordination, particularly during the first few weeks the manufactures advise avoiding alcohol while taking TCAs, although it may be safe to drink small amounts after a few weeks once the side effects have settled
  • Monoamine-oxidase inhibitors (MAOIs) – a substance called tyramine, found in some alcoholic drinks (such as wine, beer and , sherry), can cause serious side effects if taken with MAOIs, including a sudden and dangerous rise in blood pressure; if you’re taking an MAOI, it’s best to not to drink alcohol and  avoid any food or drinks that contain tyramine 
  • Other antidepressants – most other antidepressants are not known to cause problems when taken with alcohol, but manufacturers generally advise not drinking alcohol; for example you should avoid  alcohol if you are taking mirtazapine because it can make you feel very sleepy

Never stop taking any antidepressant medication just so you can drink alcohol, as stopping antidepressants suddenly can cause withdrawal effects such as flu-like symptoms, sensations in the body that feel like electric shocks and seizures (fits).

Finding out more about your medication

If you’re not sure what type of antidepressant you’re taking and don’t know whether you should avoid alcohol, speak to your GP or pharmacist. You can also call NHS Direct on 0845 46 47.

It may help to check the patient information leaflet (PIL) that comes with your medication to see whether alcohol should be avoided.

How should antidepressants be stopped?

You should always talk to your GP, prescriber or pharmacist if you are thinking of stopping your antidepressants.

A dose of antidepressants should be slowly reduced over one to two weeks if treatment has lasted less than eight weeks, and over six to eight weeks if treatment has lasted six to eight months.

This is because although antidepressants are not classed as addictive medicines, they can cause serious withdrawal symptoms if stopped abruptly. These symptoms may be entirely new or similar to some of the original symptoms of the illness.

Withdrawal symptoms

Withdrawal symptoms depend on the type of antidepressant. For example:

  • selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs) and venlafaxine commonly cause a flu-like illness (chills, muscle pain, excessive sweating, nausea and headache) and insomnia
  • SSRIs and venlafaxine can also cause dizziness or electric shock sensations
  • monoamine oxidase inhibitors (MAOIs) can cause symptoms such as irritability, agitation, sleep problems and movement disorders

The onset of withdrawal symptoms is usually within five days of stopping the medicine and will generally last for up to six weeks. If symptoms are severe, alternative approaches may have to be used, such as reintroducing another antidepressant from the same group and reducing the dose more slowly, or stopping completely and managing your symptoms.

Talk to your GP or prescriber to agree the best approach for you.

The Royal College of Psychiatrists has suggested a number of things you can do before, during and after you have stopped taking antidepressants to help you through the process.

Taking antidepressants

Stay in touch with your GP or specialist nurse when you start taking antidepressants. You should continue taking the antidepressants for at least four weeks (six weeks if you are elderly) to see how well they are working.

If your antidepressants are working, treatment should be continued at the same dose for at least six months to a year. If you have a repeated history of depression, you should continue to receive maintenance treatment for up to five years, or possibly even longer.

If you have any concerns about this information, or need any help understanding it and relating it to your own situation, you should talk to your GP or pharmacist (chemist). You can also phone NHS Direct Wales on 0845 46 47.

Other treatments:

Mindfulness

Mindfulness involves paying closer attention to the present moment and focusing on your thoughts, feelings, bodily sensations, and the world around you to improve your mental wellbeing.

The aim is to develop a better understanding of your mind and body, and learn how to live with more appreciation and less anxiety.

Mindfulness is recommended by the National Institute for Health and Care Excellence (NICE) as a way of preventing depression in people who've had three or more bouts of depression in the past.

St John's wort

St John's wort is a herbal treatment that some people take for depression. It's available from health food shops and pharmacies.

There's some evidence that it may help mild to moderate depression, but it's not recommended by doctors. This is because the amount of active ingredients varies among individual brands and batches, so you can never be sure what sort of effect it will have on you.

Taking St John's wort with other medications, such as anticonvulsants, anticoagulants, antidepressants and the contraceptive pill, can also cause serious problems.

You shouldn't take St John's wort if you are pregnant or breastfeeding, as we don't know for sure that it's safe.

Also, St John's wort can interact with the contraceptive pill, reducing its contraceptive effect.

Electroconvulsive therapy (ECT)

Electroconvulsive therapy (ECT) is sometimes recommended in cases of severe depression where other treatments, including antidepressants, haven't worked.

For most people, ECT is effective at relieving severe depression, although the beneficial effect tends to wear off after several months.

Some people also experience unpleasant side effects after having ECT, including short-term headaches, memory problems, nausea and muscle aches.

There are two types of ECT recommended by NICE – transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS). These are discussed below.

Transcranial direct current stimulation (tDCS)

Transcranial direct current stimulation (tDCS) involves placing electrodes on your head.

The electrodes are attached to a small, portable battery-operated stimulator, which delivers a constant, low-strength current to the brain. The electric current stimulates brain activity to help improve the symptoms of depression.

You'll remain awake and alert throughout the procedure, which is usually carried out by a trained clinician. However, it's sometimes possible for tDCS to be self-administered. The treatment can be used on its own or in addition to other treatments for depression.

Treatment sessions are carried out daily and last for about 20-30 minutes, with a course of treatment typically lasting several weeks.

Treatment with tDCS is safe and has been found to be effective in some cases. There's some uncertainty about the way tDCS is delivered, the number of treatments needed, and how long its effects last, so further research in these areas is needed.

NICE has more information about transcranial direct current stimulation for depression.

Repetitive transcranial magnetic stimulation (rTMS)

Repetitive transcranial magnetic stimulation (rTMS) involves holding an electromagnetic coil against your head, which delivers repetitive pulses of electromagnetic energy are at various frequencies or intensities. This stimulates a part of the brain called the cerebral cortex.

Treatment with rTMS usually involves a two to six week course of daily sessions that last about 30 minutes.

Evidence suggests that rTMS for depression is safe, although the effectiveness of treatment can vary between individuals.

NICE has more information about repetitive transcranial magnetic stimulation for depression.

Lithium

If you've tried several different antidepressants and had no improvement, your doctor may offer you a type of medication called lithium, in addition to your current treatment.

There are two types of lithium: lithium carbonate and lithium citrate. Both are usually effective, but if you are taking one that works for you, it's best not to change.

If this level of lithium in your blood becomes too high, it can become toxic. So, you'll need blood tests every three months to check your lithium levels while you're on the medication.

You'll also need to avoid eating a low-salt diet because this can also cause the lithium to become toxic. Ask your GP for advice about your diet.

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Living with

There are some key steps you can take to lift your mood and help your recovery from depression.

Take your medication

It is very important to take your antidepressants as prescribed, even if you start to feel better. If you stop taking them too soon, your depression could return.

Talk to your doctor or pharmacist if you have any questions or concerns about the medication you're taking. The leaflet that comes with your medication will have information about possible interactions with other medicines or supplements.

Check with your doctor first if you plan to take any over-the-counter remedies such as painkillers, or any nutritional supplements. These can sometimes interfere with antidepressants.

Exercise and diet 

Exercise and a healthy diet can make a tremendous difference to how quickly you recover from depression. Both improve your general health as well.

A healthy diet can help lift your mood.  In fact, eating healthily seems to be just as important for maintaining your mental health as it is for preventing physical health problems.

Research suggests that exercise can be as effective as antidepressants at reducing symptoms of depression.

Being physically active can lift your mood, reduces stress and anxiety, encourage the release of endorphins (your body's feel-good chemicals) and improve self-esteem. Exercising may also be a good distraction from negative thoughts, and it can improve social interaction.

Mindfulness

It can be easy to rush through life without stopping to notice much. Paying more attention to the present moment – to your own thoughts and feelings, and to the world around you – can improve your mental wellbeing. Some people call this awareness 'mindfulness', and you can take steps to develop it in your own life.

The National Institute for Health and Clinical Excellence (NICE) recommends 'mindfulness based cognitive therapy' for people who are currently well but have experienced three or more previous episodes of depression. It may help to prevent a future episode of depression. Read the NICE 2009 guidelines on Depression in Adults.

Talking about it

Sharing a problem with someone else or with a group can give you support and an insight into your own depression. Research shows that talking can help people recover from depression and cope better with stress.

You may not feel comfortable about discussing your mental health and sharing your distress with others. If this is the case, writing about how you feel or expressing your emotions through poetry or art are other ways to help your mood.

Search our Local Services Directory for groups who can help.

Smoking, Drugs and Alcohol

If you have depression it may be tempting to smoke or drink to make you feel better. Cigarettes and alcohol may seem to help at first, but they make things worse in the long run.

Be extra cautious with cannabis. You might see it as harmless, but research has shown a strong link between cannabis use and mental illness, including depression.

The evidence shows that if you smoke cannabis you:

  • make your depression symptoms worse
  • feel more tired and uninterested in things
  • are more likely to have depression that relapses earlier and more frequently
  • will not have as good a response to antidepressant medicines
  • are more likely to stop using antidepressant medicines
  • are less likely to recover fully

If you drink or smoke too much or use drugs, get advice and support from your GP, or read these articles about getting help if you want to stop smokingtaking drugs or drinking too much alcohol.

Work and finances

If your depression is caused by working too much or is affecting your ability to do your job, you may need time off to recover.

However, there is evidence that taking prolonged time off work can make depression worse. There's also quite a lot of evidence that going back to work can help you recover from depression.

It's important to avoid too much stress, and this includes work-related stress. If you're employed, you may be able to work shorter hours or work in a more flexible way, particularly if job pressures seem to trigger your symptoms.

Under the Equality Act (2010) all employers must make reasonable adjustments to make the employment of people with disabilities possible. This can include people who've been diagnosed with a mental illness.

If you are unable work as a result of your depression, you may be eligible for a range of benefits, depending on your circumstances. These include:

Looking after someone with depression

It's not just the person with depression who is affected by their illness. The people close to them are too.

If you're caring for someone with depression, your relationship with them and family life in general can become strained. You may feel at a loss as to what to do. Finding a support group and talking to others in a similar situation might help.

If you're having relationship or marriage difficulties, it might help to contact a relationship counsellor who can talk things through with you and your partner.

Men are less likely to ask for help than women and are also more likely to turn to alcohol or drugs when depressed.

Coping with Bereavement

Losing someone close to you can be a trigger for your depression.

When someone you love dies, the emotional blow can be so powerful that you feel it's impossible to ever recover. However, with time and the right help and support, it is possible to start living your life again. Read more about Bereavement.

Depression and Suicide

The majority of suicide cases are linked with mental disorders, and most of them are triggered by severe depression.

Warning signs that someone with depression may be considering suicide are:

  • making final arrangements, such as giving away possessions, making a will or saying goodbye to friends
  • talking about death or suicide – this may be a direct statement, such as "I wish I was dead", but often depressed people will talk about the subject indirectly, using phrases like "I think dead people must be happier than us" or "Wouldn't it be nice to go to sleep and never wake up"
  • self-harm, such as cutting their arms or legs, or burning themselves with cigarettes
  • a sudden lifting of mood, which could mean that a person has decided to commit suicide and feels better because of this decision

If you are feeling suicidal or are in the crisis of depression, contact your GP as soon as possible. They will be able to help you.

If you can't or don't want to contact your GP, call the Samaritans on 116 123, the helpline is open 24 hours a day, seven days a week. Alternatively, visit the Samaritans website or email jo@samaritans.org.

Helping a suicidal friend or relative

If you see any of the above warning signs in a friend or relative:

  • get professional help for the person
  • let them know they are not alone and that you care about them
  • offer your support in finding other solutions to their problems

If you feel there is an immediate danger, stay with the person or have someone else stay with them, and remove all available means of committing suicide, such as medication. Over-the-counter drugs such as painkillers can be just as dangerous as prescription medication. Also, remove sharp objects and poisonous household chemicals such as bleach.

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Psychotic depression

Some people who have severe clinical depression will also experience hallucinations and delusional thinking, the symptoms of psychosis.

Depression with psychosis is known as psychotic depression.

Symptoms of severe depression

Someone with severe clinical depression means feels sad and hopeless for most of the day, practically every day, and has no interest in anything. Getting through the day feels almost impossible.

Other typical symptoms of severe depression are:

  • fatigue (exhaustion)
  • loss of pleasure in things
  • disturbed sleep
  • changes in appetite
  • feeling worthless and guilty
  • being unable to concentrate or being indecisive
  • thoughts of death or suicide

Read more about the psychological, physical and social symptoms of clinical depression.

Symptoms of psychosis

Having moments of psychosis (psychotic episodes) means experiencing:

  • delusions – thoughts or beliefs that are unlikely to be true
  • hallucinations – hearing and in some cases feeling, smelling, seeing or tasting things that aren't here; hearing voices is a common hallucination

The delusions and hallucinations almost always reflect the person's deeply depressed mood – for example, they may become convinced they're to blame for something, or that they've committed a crime.

"Psychomotor agitation" is also common – this means not being able to relax or sit still, and constantly fidgeting.

Or, at the other extreme, a person with psychotic depression may have "psychomotor retardation", where both their thoughts and physical movements slow down.

People with psychotic depression are at greater risk than normal of thinking about suicide.

What causes psychotic depression?

The cause of psychotic depression is not fully understood. It's known that there's no single cause of depression and it has many different triggers.

For some, stressful life events such as bereavement, divorce, serious illness or financial worries can be the cause.

Genes probably play a part, as severe depression can run in families, although it's not known why some people also develop psychosis.

Many people with psychotic depression will have experienced adversity in childhood, such as a traumatic event.

Learn more about the causes of clinical depression.

Treating psychotic depression

Treatment for psychotic depression involves:

  • medication – a combination of antipsychotics and antidepressants can help relieve the symptoms of psychosis
  • psychological therapies – the one-to-one talking therapy cognitive behavioural therapy (CBT) has proved effective in helping some people with psychosis
  • social support – support with social needs, such as education, employment or accommodation

The person may need to stay in hospital for a short period of time while they're receiving treatment.

Sometimes electroconvulsive therapy (ECT) may be recommended if the patient has severe depression and other treatments, including antidepressants, haven't worked.

Treatment is usually effective, but follow-up appointments so that the person can be closely monitored are usually required.

Getting help for others

People with psychosis are often unaware that they're thinking and acting strangely.

As a result of this lack of insight, it's often down to the person's friends, relatives or carers to seek help for them.

If you're concerned about someone you and think they may have psychosis, you could contact their social worker or community mental health nurse if they've previously been diagnosed with a mental health condition.

If this is the first time they've shown symptoms of psychosis, contact their GP or take them to A&E.

If you think the person’s symptoms are placing them or others at possible risk of harm you can:

  • take them to the nearest accident and emergency (A&E) department, if they agree
  • call their GP or local out-of-hours GP
  • call 999 and ask for an ambulance

Support and advice

The following links provide more information on

Driving

If you have been diagnosed with psychotic depression, it's your legal obligation to tell the Driver and Vehicle Licensing Agency (DVLA) as it could affect your driving ability.

GOV.UK provides details about telling the DVLA about a medical condition.

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The information on this page has been adapted by NHS Wales from original content supplied by NHS Choices.
Last Updated: 19/09/2017 10:57:03